Infant and young child feeding in emergencies

Why IYCF-E important for survival of children in the Syria crisis

Key messages

• Supporting and protecting optimal infant and young child feeding in the Syria crisis is an essential intervention to save children’s lives.

• While there is currently a lack of information on the health, nutrition situation and survival of infants and young children we know that the established risks of poor feeding practices are amplified under the current conditions faced by infants in the Syria crisis - additional data on the need would be useful but we already have evidence do we need a proven catastrophe before acting?

• There needs to be funding for an IMMEDIATE appropriate IYCF-

E response in the region (that following international guidance)

Importance of appropriate infant and young child feeding for survival in emergencies

• Breastfeeding is safe, free and a crucial life-saving intervention for vulnerable children whose risks of death increase markedly in emergencies– Risk of mortality can increase up to 70 times– Even among previously healthy populations, mortality rates can

soar 20-fold in as little as 2 weeks (WHO 2004)

• Emergencies exacerbate the risks of not breastfeeding or mixed feeding

• Donations of breastmilk substitutes and other milks undermine breastfeeding and cause illness and death

Importance of IYCF-E for children over 6 months

• Continued breastfeeding is crucial in reducing the risk of diarrhoea and other illnesses in children older than 6 months, which is heightened in emergencies, and also for preventing undernutrition.

• Safe, adequate, and appropriate complementary feeding, which significantly contributes to prevention of undernutrition and mortality in children after 6 months, is often jeopardized during emergencies and needs particular attention.

The evidence: impact of breastfeeding on mortality

• A non-breastfed child is 14 times more likely to die in the first 6 months compared to an exclusively breastfed child in developing countries.

• These risks are amplified many times in an emergency

Diarrhoea mortality Pneumonia mortality All cause mortality0

2

4

6

8

10

12

14

16

1 1 1

10.53

15.1314.4

Exclusive breastfeedingNot breastfeeding

Lancet Nutrition Series 2008.

Lancet 2013 Nutrition Series: 45% of child deaths are due to undernutrition; 12% of those deaths or 800,000 deaths, attributable to sub-optimal breastfeeding

Lancet 2013, Nutrition Series (paper 1)

Zinc deficiency

Vitamin A deficiency

Severe wasting

Wasting

Sub-optimal breastfeeding

Fetal growth restriction

Underweight

Stunting

Combined effects

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0

1.7

2.3

7.8

11.5

11.6

11.8

17.0

17.0

45.4

Percentage of deaths

Zinc deficiency

Vitamin A deficiency

Severe wasting

Wasting

Sub-optimal breastfeeding

Fetal growth restriction

Stunting

Underweight

Combined effects

0 2,000,000 4,000,000

116,000

157,000

540,000

800,000

804,000

817,000

1,179,000

1,180,000

3,149,000

Annual numbers of deaths

Lancet 2013 diarrhea-pneumonia series: breastfeeding promotion has large impact on child deaths due to diarrhea and pneumonia

 

Source: Lancet 2013, Childhood Pneumonia and Diarrhea Series, Paper 2.

Antibiotics for dysentery

Zinc for treatment of diarrhea

Vitamin A supplementation

Hygienic disposal of children's stools

Rotavirus vaccine

ORS

Improved sanitation

Handwashing with soap

Hib vaccine

Zinc supplementation

Improved water source

Case management of pneumonia infections

Breastfeeding promotion

Case management of neonatal infections

Pneumococcal vaccine

- 50,000 100,000 150,000 200,000 250,000 300,000 350,000 Lives saved

Early initiation of breastfeeding saves newborn lives

8

• Initiation of breastfeeding within the first hour could prevent up to 20% of neo-natal deaths from all causes

• Lancet 2013: initiation within the first 24 hours associated with 45% reduction in all-cause neo-natal mortality

Newborns are particularly vulnerable in emergencies.

Sources: Singh K, Srivastava P. The effect of colostrum on infant mortality: Urban rural differentials. Health and Population 1992;15(3&4):94–100.Edmond, K et al. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics 2006: 117(3):e380-6. Mullany L. et al. Breastfeeding patterns, time to Initiation and mortality risk among newborns in southern Nepal. The Journal of Nutrition 2008: 138; 599-603. Lancet 2013, Nutrition Series, Paper2.

No active protection through mother’s antibodies

Infant formula powder is not

sterile

Increases food insecurity and dependency

Bottle feeding increases risk

Bottle and teats extra source of

infection

Costly in time, resources and

care

Artificial feeding is always risky; much more so in emergencies

Excess risk of morbidity and mortality: some examples

• Botswana emergency 2005-6: Non-breastfed infants 50 times more likely to be hospitalised and much more likely to die.

• Conflict, Guinea-Bissau, 1998: non-breastfed children aged 9-20 months old were 6 times more likely to have died during the first 3 months of the war compared with children still breastfeeding.

Botswana 2005-6 article at: http://fex.ennonline.net/29/diarrhoearisk.aspx

Guinea Bissau: Jacobsen 2003

Statistical significant relationship between prevalence of diarrhea and receipt of infant formula: Indonesia earthquake 2006

0

5

10

15

20

25

30

25.4

11.4

Pro

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ren

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From: Assefa F, et al. Field Exchange 2008;34:30. Indonesia

World Health Assembly Resolution 63.23, 2010 applies worldwide: also in Syria!

• WHA 63.23 urges member states to implement the Ops Guidance on IYCF-E.

• The “Humanitarian Charter and Minimum Standards in Disaster Response”, commonly known as “Sphere Standards”, has two new IYCF standards in Sphere 2011:

– Infant and young child feeding standard 1: Policy guidance and coordination

– Infant and young child feeding standard 2: Basic and skilled support

The Sphere Project

Infant and Young Child Feeding in Emergencies is included in Sphere - which apply to ALL emergencies

Infant and Young Child Feeding in Syria pre-crisis

Pre-crisis IYCF practices were far from optimal: • 46% initiating breastfeeding within the first hour of birth • 43% exclusive breastfeeding • 23% of mothers continuing to breastfeed at 2 years. • 37% providing timely introduction of complementary food• Approximately 10% of infants less than 6 months in Syria

were not breastfed at all: – this means that the vast majority of infants at least started

breastfeeding/were partially breastfed• 28% stunting is high, points to poor IYCF practices as a

major factor.

All data from 2009 reported in UNICEF. State of the World’s Children, 2012

Current situation: factors which herald a growing IYCF-E crisis which will undermine child survival

• Across the region the risk factors are evident: – Breastfeeding is being undermined by a proliferation of

myths/misconceptions about breastfeeding. – Widespread donations and untargeted distributions of

breastmilk substitutes (BMS) and other milk products, – Lack of skilled support for breastfeeding mothers – Lack of appropriate support for children with no

possibility to breastfeed. – Lack of complementary foods; concern about the poor

micronutrient content of food – Patchy health services with little IYCF/IYCF-E capacity – Poor/strained WASH facilities impacting on ‘safe’ infant

feeding outcomes.

Breastfeeding issues

Myths and misconceptions surrounding breastfeeding are common especially related to stress and lack of food.

Mothers (and Grandmothers) are seeking help and support for breastfeeding but there is not the necessary skilled support available.

Health workers lack of knowledge on breastfeeding are actually perpetuating myths and encouraging mothers to formula feed. A common attitude found being: ‘breastfeeding is better but mothers are too busy/stressed/not eating enough – we will promote this later when we have time’

Photos from Syria response

Large sacks of milk powder – open to elements and contamination given to ‘mothers with babies’

Ad-hoc donations of infant formula and other milks given to ‘any mother with a young child’ regardless if breastfeeding or not. No additional education, resources or support is provided.

Additional issues

• Malnutrition not an issue pre-crisis – so ‘nutrition’ not prioritised • IYCF-E been ignored and/or got lost under health agenda. • No overall coordination, advocacy, information-sharing mechanism for IYCF-E in the

region – hard to establish gaps, needs, share lessons, etc.• Lots of ‘new’ actors in the region that don’t have experience / knowledge on

humanitarian issues but are providing ‘nutrition’ support through donations of infant formula, etc.

• Lack of awareness amongst donors, governments, INGOs, local NGOs, civil society organisations, diaspora, etc, of the critical life-saving importance of IYCF-E and the international standards (Ops Guidance on IYCF-E, Sphere)

• Few assessments have included IYCF-E and nutrition – even then can’t interpret due to wording and/or not appropriate questions. (Very few IYCF-E specific assessments).

• Lack of capacity in nutrition and especially IYCF-E amongst health professionals, lNGOs, local NGOs, civil society, etc.

• In some locations few ‘traditional’ nutrition agencies on the ground – due in part to lack of funding opportunities for nutrition.

• Particularly challenging in places like Northern Syria where there is the absence of UN.

• Inadequate funding for IYCF-E

What is needed to support IYCF-E in the Syria crisis

Recognition by all that IYCF-E is a critical emergency response that is needed IMMEDIATELY

Save lives, prevents morbidity, prevents acute and chronic malnutrition, and if we don’t support children in the 1000 day window

of opportunity even if the crisis stops soon children will be impacted for the rest of their lives.

Prevention should be the primary aim of the nutrition response

What is needed to support IYCF-E in the Syria crisis

Regional Roving IYCF-E Specialist – advocacy, coordination, cross-learning in the region, etc

Assessments – include IYCF-E in on-going assessments (need to ensure questions are appropriate and can be interpreted) and undertake IYCF-E specific assessments to improve programming

Capacity Building on IYCF-E – all levels and all elements Advocacy to INGOs, local NGOs, civil society, etc to stop

donations and untargeted distributions of BMS and other milk products

Support to ‘new’ NGOs, civil societies who are unaware of humanitarian standards, IYCF-E guidance, and IYCF-E issues on how to incorporate these into their programmes/activities.

Funding for above and for IYCF-E programming applicable to the country and context but in line with the Operational Guidance on IYCF-E.